The study of the health workforce has gained in prominence in recent years, as the dynamic interconnections between human resource issues and health system effectiveness have come into sharper focus. This paper reviews lessons relating to strategic management challenges emerging from the growing literature in this area. Workforce issues are strategic: they affect overall system performance as well as the feasibility and sustainability of health reforms. Viewing workforce issues strategically forces health authorities to confront the yawning gaps between policy and implementation in many developing countries.Lessons emerge in four areas. One concerns imbalances in workforce structure, whether from a functional specialization, geographical or facility lens. These imbalances pose a strategic challenge in that authorities must attempt to steer workforce distribution over time using a limited range of policy tools. A second group of lessons concerns the difficulties of central-level steering of the health workforce, often critically weak due to the lack of proper information systems and the complexities of public sector decentralization and service commercialization trends affecting the grassroots.A third cluster examines worker capacity and motivation, often shaped in developing countries as much by the informal norms and incentives as by formal attempts to support workers or to hold them accountable. Finally, a range of reforms centering on service contracting and improvements to human resource management are emerging. Since these have as a necessary (but not sufficient) condition some flexibility in personnel practices, recent trends towards the sharing of such functions with local authorities are promising.The paper identifies a number of current lines of productive research, focusing on the relationship between health policy reforms and the local institutional environments in which the workforce, both public and private, is deployed.
Decentralisation occupies an important space in debates over public-sector reform in doi moi Vietnam. This article assesses the changing distribution of roles, responsibilities and resources across levels of government over the past decade. Vietnam is incrementally transfering greater administrative and fiscal responsibilities to the provincial level. In addition, the Communist Party is attempting to prevent local corruption through a much touted "grassroots democratisation" initiative. Yet such moves towards decentralisation, however cautious, are problematic in terms of their bureacratic politics and potential impacts on poverty. Incentives for bureacratic actors and local leaders to transfer meaningful control downwards are weak or non-existent within the current governance structure, which centralises political power and emphasises hierarchical, sectoral controls over decision-making and resources. And decentralisation trends are exacerbating the weak administrative and fiscal capacities of poorer provinces, threatening to reinforce rather than reduce Vietnam's widening regional and rural-urban disparities. A more proactice role for the centre in redistributing resources, providing technical support and establishing a facilitative policy framework will be crucial if decentralisation is to contribute towards improved socioeconomic outcomes in Vietnam's poorest regions. In existing and necessary future arrangements, requirements and asociated mechanisms of accountability are of key significance.
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